Physicians Lounge^TM

1.

What is your Race?

2.

What is your Ethnicity?

3.

What is your Religion?

4.

What is your highest Education level?

5.

What is your Primary Language?

6.

What is your Secondary Language?

7.

What is your Age?

8.

What is your Gender?

9.

Which Country are you located in?

10.

Do you have a Doctor?

11.

When did you last visit a Doctor?

12.

Are you satisfied with your current Doctor?

13.

Are you able to freely discuss your health issues with your Doctor?

14.

Are you able to discuss issues related to our private body parts with your Doctor?

Yes - Comfortably

Yes - Uncomfortably

No - This prevents me from seeking medical care

No - This does not prevent me from seeking medical care

No - My health has suffered due to this

15.

Does your Doctor speak your language?

16.

Do you or someone in your family need an interpreter?

17.

Do you prefer a female or male Doctor?

18.

Do you feel that your health has suffered because of your race, ethnicity, language or religion?

19.

Do you have any disability?